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    v1.0.28
    OpenPayerPolicy UpdatesPain ManagementKaiser Permanente SIJ Fusion/RFA Coverage Update |…
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    ModifiedKaiser PermanentePolicy N/A

    Clinical Review Criteria — Sacroiliac Joint Procedures for Pain (SI joint injections, neurotomy/RFA, and fusion)

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    Clinical review criteria for sacroiliac (SI) joint injections, neurotomy (RFA), and fusion covering Kaiser Foundation Health Plan of Washington members and providers. Applies to Medicare and non‑Medicare members as specified.

    Policy Summary
    PayerKaiser Permanente
    PolicyClinical Review Criteria — Sacroiliac Joint Procedures for Pain
    Policy CodePolicy N/A
    Change TypeRevised SI Joint Fusion criteria to allow coverage in certain situations
    Effective DateN/A
    Last ReviewJun 3, 2025
    Next Review DateN/A
    Key ActionObtain and submit documentation of at least 6 months of conservative management and required imaging and injection records when requesting prior authorization for SIJ fusion or RFA.
    SourceLink

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    POLICY UPDATE CHANGES

    Revised SI Joint Fusion criteria to allow coverage in certain situations.

    Merged Radiofrequency Neurotomy of SI joint and SI Joint Procedures Criteria.

    Added future dated Medicare policy reference for minimally invasive arthrodesis of the sacroiliac joint.

    2injections required
    2lateral branch blocks required
    6 monthsconservative therapy duration
    >=75%diagnostic relief threshold
    BMI > 40relative contraindication
    27278-27280fusion CPT range

    Coverage Criteria

    SI Joint Neurotomy (RFA) criteria

    SI Joint Neurotomy (RFA) is considered medically necessary when ALL of the following are met:

    RFA necessity: A. At least 2 intraarticular SI joint steroid injections with location confirmation by contrast spread or both A/P and lateral views. If the first injection provides <80% relief as measured by a standard pain questionnaire, a second steroid injection at least one month later is required. B. If intraarticular steroid injections do not provide long-term relief, a trial of at least 2 lateral branch anesthetic injections (location confirmed by contrast spread or both A/P and lateral views) demonstrating >=80% reduction in pain measured by a standard pain scale for the expected duration of the anesthetic, with a minimum 2-week interval between injections. If anesthetic injection is successful, patient is eligible for SI Joint Neurotomy (RFA).2 injections; >=80% pain reduction

    Non‑Medicare member criteria per policy

    Minimally Invasive SI Joint Fusion criteria

    Percutaneous or minimally invasive SIJ fusion is considered medically necessary when ALL of the following are met:

    MIS SIJ Fusion initial criteria: 1) Adult >=18 years with sacroiliac joint pain >6 months (or >18 months for pregnancy‑induced pelvic girdle pain). 2) Significant pain originating from the SIJ (e.g., pain >=5/10). 3) Pain located at or close to the posterior superior iliac spine (PSIS) with possible radiation and ability to localize pain (Fortin finger test). 4) SIJ diagnosed as pain source by response to 3 or more provocative maneuvers. 5) Clinical documentation that pain limits activities of daily living. 6) Failure of >=6 months of alternative treatments including anti‑inflammatory medication (NSAID or acetaminophen) and a trial of supervised physical therapy in the last 12 months (minimum 3 visits with >75% attendance). 7) Trials of at least 2 intraarticular SIJ steroid injections (location confirmed by contrast spread or A/P and lateral views); if these fail to provide long‑term relief, at least 2 lateral branch anesthetic injections with >=80% pain reduction and a minimum 2‑week interval between anesthetic injections. 8) Absence of alternative or contributing diagnoses (e.g., ipsilateral hip osteoarthritis, L5‑S1 degeneration, tumor, infection, fracture). 9) Imaging: CT or MRI excludes destructive lesions; ipsilateral hip imaging excludes osteoarthritis; lumbar imaging excludes neural compression or other degenerative causes of pain.SIJ pain >6 months; pain >=5/10; >=3 positive maneuvers; >=6 months conservative therapy; 2 injections each for diagnostic/therapeutic steps

    Operative candidates should be nicotine‑free at least 6 weeks prior to elective surgery; BMI >40 is a relative contraindication.

    Open SI Joint Fusion criteria

    Open sacroiliac joint fusion is medically necessary when ALL of the following are met:

    Open fusion criteria: 1) Appropriate imaging studies demonstrate localized sacroiliac joint pathology. 2) The individual is a nonsmoker, or will refrain from tobacco use for at least 6 weeks prior to planned surgery in the absence of progressive neurologic compromise (documentation of nicotine cessation via lab test required if recent use). 3) ONE of: post‑traumatic SIJ injury (e.g., pelvic ring fracture), adjunctive treatment for SIJ infection or sepsis, management of sacral tumor (e.g., partial sacrectomy), or performed as part of multisegmental long fusion for correction of spinal deformity.Imaging-confirmed SIJ pathology; tobacco cessation requirement; one qualifying indication

    Open fusion is not covered for other indications (e.g., mechanical low back pain, sacroiliac joint syndrome, degenerative SIJ, radicular syndromes).

    Coverage groups: SIJ Fusion and SIJ RFA

    Coverage stance varies by procedure and payer (Medicare vs Non‑Medicare) and is contingent on meeting applicable policy statements and criteria.

    Minimally Invasive SIJ Fusion (MIS SIJF): MTAC concluded MIS SIJF does not meet Kaiser Permanente Medical Technology Assessment Criteria; nonetheless, MPC actions revised criteria to allow coverage in certain situations for non‑Medicare members when applicable policy statements are met. Evidence includes short‑term RCT benefit and observational support to 24 months, but long‑term randomized data are insufficient; safety concerns include device‑related complications and revisions. Results should not be generalized to devices/approaches other than those studied (e.g., lateral transiliac iFuse).See policy criteria for specifics

    Coverage varies by payer and device; refer to applicable policy statements.

    Conventional Thermal RFA for SIJ Denervation: Conventional (thermal) RFA is supported by a low‑quality body of evidence suggesting safety and possible effectiveness for reducing SIJ pain, but uncertainty remains regarding function and quality‑of‑life benefits and comparative effectiveness. Medicare: SI Joint Neurotomy (RFA) is considered Not Medically Necessary in some jurisdictions per Medicare LCDs; Non‑Medicare: considered medically necessary when the applicable policy criteria are met.Hayes Rating C

    Open sacroiliac joint fusion is not covered for indications outside the specific situations listed in the policy. The procedure is limited to the defined criteria (e.g., post‑traumatic SIJ injury, adjunctive treatment for SIJ infection/sepsis, management of sacral tumor, or when performed as part of multisegmental long fusion for spinal deformity); it is considered experimental, investigational, or unproven for common indications such as mechanical low back pain, sacroiliac joint syndrome, degenerative sacroiliac joint, and radicular pain syndromes.

    The evidence is insufficient to determine the safety and efficacy of sacroiliac joint fusion in patients who were excluded from the randomized trials or who have significant comorbidities. MTAC reviews note uncertainty for patients with other sources of back pain and for those with conditions such as osteoporosis, diabetes, or cardiovascular disease; available randomized and observational data do not establish long‑term comparative benefit or safety in these populations.

    For Medicare determinations, some SIJ fusion procedure codes are identified as not medically necessary. Specifically, CPT code 27278 (arthrodesis, sacroiliac joint, percutaneous, with image guidance, including placement of intra‑articular implant(s)) is listed as not medically necessary in applicable Medicare policy language.

    Minimally invasive sacroiliac joint fusion (MIS SIJF) was evaluated by the Kaiser Permanente Medical Technology Assessment Committee and does not meet MTAC criteria for broad adoption. MTAC cited limited long‑term randomized evidence, industry‑sponsored trials with short‑term benefits, and safety concerns including device‑related complications and revisions; documentation of MTAC findings and the assessment conclusions should be included in review and authorization processes.

    MIS SIJF was previously adopted as non‑coverage when the MTAC criteria were not met. MTAC conclusions and subsequent MPC deliberations found insufficient long‑term comparative evidence and unresolved safety questions, supporting the policy position of non‑coverage except where specific, documented criteria are satisfied.

    Coding and Diagnostic Thresholds

    SI Joint Injection CPTCPTCovered
    27096Injection procedure, sacroiliac joint, diagnostic or therapeutic
    SI Joint Neurotomy / RFACPTCovered
    64625Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)
    SI Joint Fusion CPT codesCPTCovered
    27278Arthrodesis, sacroiliac joint, percutaneous, with image guidance, including placement of intra-articular implant(s), without placement of transfixation device
    27279Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device
    27280Arthrodesis, sacroiliac joint, open, includes obtaining bone graft, including instrumentation, when performed
    Diagnostic anesthetic relief threshold
    Diagnostic relief threshold>=75% symptom relief after image-guided intraarticular anesthetic injection
    Measurement methodMeasured by a standard pain questionnaire following image-guided intraarticular anesthetic injection
    PurposeUsed as the most definitive diagnostic evaluation to confirm the SIJ as pain source
    Supporting referencesPolly 2017; Thawrani 2019 cited in background for diagnostic threshold
    Hayes evidence rating threshold
    Hayes evidence ratingRating C for conventional (thermal) radiofrequency ablation (RFA) for SIJ denervation

    Provider Actions and Authorization Requirements

    Prior Authorization

    Prior authorization overview — injections exempt; RFA and fusion require documentation

    For non‑Medicare members, prior authorization is not required for SI joint injections (CPT 27096). SI joint neurotomy (RFA) and SI joint fusion require submission of documentation demonstrating that the applicable medical necessity criteria are met before approval.

    • CPT 27096 — injections: medical necessity review not required for non‑Medicare members
    • SI joint neurotomy and fusion — prior authorization contingent on meeting policy criteria and documentation
    Prior Authorization

    Prior authorization required for SIJ fusion (CPT 27278–27280)

    Prior authorization is required for SI joint fusion CPT codes 27278–27280 when coverage is contingent on meeting the applicable policy criteria; Medicare and non‑Medicare determinations are specified separately in the policy.

    • CPT 27278, 27279, 27280 require criteria-based authorization for coverage
    • Policy distinguishes Medicare vs non‑Medicare coverage positions

    Conservative Treatment Requirements

    Trial of medications and structured physical therapy

    Covered interventions for fusion consideration require a prior trial of medications and structured physical therapy:

    Conservative treatment duration: Patients must have failed at least 6 months of conservative management, including anti‑inflammatory medication (NSAIDs or acetaminophen) and a supervised trial of physical therapy (minimum 3 visits with >75% attendance) before consideration of percutaneous/minimally invasive SIJ fusion.>=6 months

    Per policy step‑therapy requirement for non‑Medicare members.

    Documentation that conservative therapies were tried and failed is expected per applicable policy statements.

    Documentation that conservative therapies were tried and failed is expected when requesting SIJ procedures:

    Documentation expectation: Submit clinical documentation showing failure of conservative therapies, including the last 6 months of clinical notes from the requesting provider/specialist and imaging reports that demonstrate the required diagnostic and imaging criteria. Documentation should confirm trials and results of intraarticular and lateral branch injections, pain scores, functional limitation, and tobacco‑cessation status when applicable.

    Frequency Limits and Procedural Sequencing

    Diagnostic/therapeutic SIJ injections and lateral branch blocks
    Intraarticular steroid injectionsAt least 2 intraarticular SIJ steroid injections with location confirmed by contrast spread or both AP and lateral views
    Response to first injectionIf first injection provides <80% relief, a second steroid injection at least one month later is required
    Lateral branch anesthetic injectionsTrial of at least 2 anesthetic injections to the lateral branch (location confirmed) with >=80% pain reduction for expected anesthetic duration
    Timing between anesthetic injectionsMinimum 2-week interval between the two lateral branch anesthetic injections
    Radiofrequency ablation (CPT 64625) — image guidance requirement
    Image guidance requirement

    Imaging Requirements

    Billing Rule

    Imaging for SIJ fusion and injections — CT/MRI and AP/lateral fluoroscopic confirmation

    For SIJ injections, obtain imaging that demonstrates sacroiliac joint evaluation (CT or MRI) to exclude destructive lesions and use AP and lateral fluoroscopic views or contrast spread to confirm injection location.

    • SIJ imaging: CT or MRI to exclude destructive lesions and ipsilateral hip/lumbar pathology
    • Injection location confirmation: contrast spread or both AP and lateral fluoroscopic views
    Billing Rule

    Image guidance required — fluoroscopy or CT for RFA and SIJ fusion

    Image guidance with fluoroscopy or computed tomography is required for SI joint radiofrequency ablation (CPT 64625) and for SI joint fusion procedures per their CPT descriptions.

    • CPT 64625 requires image guidance (fluoroscopy or CT)

    Definitions

    Provocative SIJ maneuvers
    FABER (Patrick's) TestFlexion, Abduction and External Rotation maneuver to apply tensile force on anterior SI joint and reproduce symptoms
    Thigh Thrust (Posterior Shear) TestApplies anteroposterior shear stress on the SI joint with hip/knee flexed to reproduce pain
    Pelvic Gapping (SIJ distraction) TestApplies tensile forces to anterior SI joints by posteriorly directed force on ASIS to reproduce symptoms
    Pelvic Compression TestApplies steady downward pressure through lateral ilium to compress SI joint and reproduce symptoms
    Gaenslen's TestApplies torsional stress on the SI joints with one leg near table edge and contralateral hip flexed
    Radiofrequency ablation (RFA) — definition

    Background and Evidence Summary

    The sacroiliac joint (SIJ) is an anatomical connection between the sacrum and pelvis and can be the source of chronic low back pain in a substantial minority of patients (commonly cited estimates in the literature). Diagnosis is challenging because presentation overlaps lumbar spine and hip pathology; the policy emphasizes that a definitive diagnostic evaluation relies on image‑guided intraarticular anesthetic injection producing substantial symptom relief (the document references diagnostic injection thresholds and image confirmation). Conservative therapies (oral analgesics, structured physical therapy, injections, and RFA) are first‑line, with SIJ fusion reserved for select patients who meet detailed imaging, diagnostic, and conservative‑treatment criteria.

    Overall evidence for SIJ fusion and for conventional thermal radiofrequency ablation is limited and characterized by short‑term randomized data and observational follow‑up. MTAC concluded that minimally invasive SIJF does not meet Kaiser Permanente Medical Technology Assessment Criteria due to insufficient long‑term randomized evidence and safety uncertainties; two industry‑sponsored RCTs show moderate short‑term benefit but do not establish durable comparative effectiveness. For conventional thermal RFA, the evidence body is of low quality (Hayes Rating C), suggesting possible pain reduction but uncertainty about functional and quality‑of‑life benefits. These evidence limitations inform the policy's conservative stance and documentation requirements.

    Not Covered

    The policy explicitly states that open sacroiliac joint fusion is not covered for common indications such as mechanical low back pain, sacroiliac joint syndrome, degenerative sacroiliac joint disease, or radicular pain syndromes. Similarly, minimally invasive SIJ fusion is not covered when the policy’s required diagnostic, imaging, conservative‑therapy, or procedural criteria are not met; MTAC findings and the limited evidence base underpin these not‑covered determinations.

    Consistent with the MTAC conclusion, the policy lists minimally invasive sacroiliac joint fusion as not covered when MTAC criteria are not satisfied. MTAC cited insufficient long‑term comparative evidence and concerns about generalizing results beyond the lateral transiliac iFuse studies; these conclusions supported previous non‑coverage decisions reflected in the policy.

    Policy Summary
    PayerKaiser Permanente
    PolicyClinical Review Criteria — Sacroiliac Joint Procedures for Pain
    Policy CodePolicy N/A
    Change TypeRevised SI Joint Fusion criteria to allow coverage in certain situations
    Effective DateN/A
    Last ReviewJun 3, 2025
    Next Review DateN/A
    Key ActionObtain and submit documentation of at least 6 months of conservative management and required imaging and injection records when requesting prior authorization for SIJ fusion or RFA.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Diagnostic ThresholdsProvider Actions and Authorization RequirementsConservative Treatment RequirementsFrequency Limits and Procedural SequencingImaging RequirementsDefinitionsBackground and Evidence SummaryNot Covered

    Clinical decision-making should reflect payer-specific coverage determinations.

    ImplicationLow-quality evidence suggests possible pain reduction but uncertainty about function and QOL benefits
    ScopeApplies to conventional (continuous, thermal) RFA in adults with chronic low back pain originating from the SIJ who failed conventional treatment
    Prior Authorization

    Prior authorization for SIJ radiofrequency ablation (CPT 64625)

    Prior authorization applies for SI joint radiofrequency ablation (CPT 64625) when the procedure is provided to non‑Medicare members and the provider submits documentation that the applicable RFA criteria are met.

    • CPT 64625 — RFA with image guidance: non‑Medicare considered medically necessary when criteria met; Medicare considered not medically necessary in this policy
    Step Therapy

    Require ≥6 months of conservative management before fusion

    Patients must have failed at least 6 months of conservative management — including anti‑inflammatory medication (NSAIDs or acetaminophen) and a supervised trial of physical therapy — before percutaneous/minimally invasive SIJ fusion is considered.

    • Minimum 6 months of alternative treatments required
    • Physical therapy: supervised, minimum 3 visits with >75% attendance
    Note

    Conservative management required; MIS SIJF and RFA considered after failed conservative care

    Conservative nonsurgical management is the expected comparator; MIS SIJ fusion did not meet MTAC criteria, and RFA is considered after failure of conventional treatments per the policy evidence reviews.

    • Conservative therapies must be tried and documented as failed before progressing
    • MTAC concluded MIS SIJF does not meet criteria — impacts coverage stance
    Documentation Required

    Required documentation — recent clinical notes and imaging reports

    Submit the last 6 months of clinical notes from the requesting provider and/or specialist and the last 6 months of imaging reports (if applicable) to support medical necessity for SIJ procedures.

    • Clinical notes — last 6 months
    • Imaging reports — last 6 months (when applicable)
    Documentation Required

    Procedure documentation — support criteria for CPT 27278/27279/27280

    When SIJ fusion is considered medically necessary, documentation must clearly demonstrate that the specific policy criteria for CPT 27278, 27279, or 27280 are met.

    • Evidence that all inclusion criteria and absence of exclusions are documented for the selected CPT code
    Denial Risk

    Denial triggers — SI joint fusion lacks required medical necessity documentation

    Percutaneous or open SI joint fusion will be denied when indications do not meet the listed medical necessity criteria — for example, if imaging, symptom duration, provocative exam findings, conservative therapy, or exclusion of alternative diagnoses are insufficient.

    • Denial triggers include failure to document required imaging findings, insufficient duration of symptoms or conservative therapy, fewer than required positive provocative maneuvers, or presence of alternative diagnoses
    Denial Risk

    MTAC nonconcurrence — MIS SIJF does not meet MTAC criteria

    Minimally invasive sacroiliac joint fusion (MIS SIJF) for SI joint pain/dysfunction does not meet the Kaiser Permanente Medical Technology Assessment Committee (MTAC) criteria.

    • MTAC nonconcurrence affects coverage decisions and is noted in the policy evidence conclusions

    Required documentation supports medical necessity determinations and prior authorization review.

    CPT 64625 requires image guidance (fluoroscopy or computed tomography) per code description
    Code referencedCPT 64625 — Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance
    Repeat frequencySpecific repeat frequency limits are not provided in the cited policy text
  1. CPT 27278–27280 include image guidance in the procedure descriptions
    2. Procedure definitionA percutaneous outpatient procedure using radiofrequency energy to heat tissue to the point of destruction to prevent transmission of pain signals from sensory nerves
    SettingPerformed in an outpatient percutaneous manner
    Intended effectDenervation of nerves innervating the sacroiliac joint to reduce chronic low back pain
    SI Joint Fusion (SIJF) — definition
    SIJF definitionArthrodesis of the sacroiliac joint performed percutaneously, minimally invasive, or open; may include placement of intra-articular implants or transfixing devices (CPT 27278–27280)
    ApproachesPercutaneous, minimally invasive (indirect visualization), or open surgical approaches documented in CPT descriptions
    PurposeFusion immobilizes the SI joint to eliminate motion believed to cause inflammation and pain